Management of Hip

Dislocations
Dr. Ahmed ashour
Team 4
Khoula hosp.

Introduction

Hip dislocations caused by significant force:

Association with other fractures
Damage to vascular supply to femoral head

Thus, high chance of complications

Anatomy

Ball and socket typical synovial joint.

Femoral head: slightly asymmetric, forms 2/3 sphere.
Acetabulum: inverted U shaped articular surface.
Ligamentum teres, with artery to femoral head, passes through
middle of inverted U.

Joint Contact Area

Throughout ROM:

40% of femoral head is in contact with

acetabulum.

10% of femoral head is in contact with

labrum.

Acetabular Labrum

Strong fibrous ring

Increases femoral head coverage
Contributes to hip joint stability

Hip Joint Capsule

Extends from intertrochanteric ridge of
proximal femur to bony perimeter of
acetabulum
Has several thick bands of fibrous tissue (3
lig) ===Iliofemoral ligament
Upside-down Y
Blocks hip hyper-extension
Allows muscle relaxation while standing

The ligaments of hip joint

The primary capsular fibers run longitudinally and are

supplemented by much stronger ligamentous condensations that
run in a circular and spiral fashion.

Blood Supply to Femoral Head

(3 sources)
2. Ascending Cervical Branches
Arise from ring at base of neck.
Ring is formed by branches of medial and lateral
circumflex femoral arteries.
Penetrate capsule near its femoral attachment and
ascend along neck.
Perforate bone just distal to articular cartilage.
Highly susceptible to injury with hip dislocation.

Sciatic Nerve

Composed from roots of L4 to S3.

Peroneal and tibial components differentiate early,
sometimes as proximal as in pelvis.
Passes posterior to posterior wall of acetabulum.
Generally passes inferior to piriformis muscle, but
occasionally the piriformis may split the peroneal and
tibial components

Hip Dislocation: Mechanism of Injury

Almost always due to high-energy trauma.

Most commonly involve unrestrained occupants
in RTAs.
Can also occur in pedestrian-RTAs, falls from
heights, industrial accidents and sporting injuries.

Classification
Multiple systems exist:
Thompson and epstein
Stewart and milford
AO/OTA Classification

Thomas and Epstein Classification

of Hip Dislocations
Most well-known
Type I

Pure dislocation with at most a small posterior

wall fragment.

Type II

Dislocation with large posterior wall fragment.

Type III

Dislocation with comminuted posterior wall.

Type IV

Dislocation with acetabular floor fracture

(probably transverse + post. wall acetabulum
fracture-dislocation).

Type V

Dislocation with femoral head fracture.

Limb position ?
according to types

Posterior Dislocation

Generally results from axial load applied to

femur, while hip is flexed.
Most commonly caused by impact of
dashboard on knee.

Types of Posterior Dislocation

Postero-superior (iliac)
Posterior
ischial

Mechanism of
Anterior
Dislocation

Extreme abduction with external rotation of

hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.

Types of anterior dislocation

Pubic
Obturator
Perineal

Effect of Dislocation on Femoral Head

Circulation
When capsule tears, ascending cervical
branches are torn or stretched.
Artery of ligamentum teres is torn.
Some ascending cervical branches may remain
kinked or compressed until the hip is reduced.
Thus, early reduction of the dislocated hip can
improve blood flow to femoral head.

Associated Injuries

Mechanism: knee vs. dashboard injury

Contusions or fractures of distal femur
Patella fractures, knee injuries
Foot fractures, if knee extended

Cont
Other associated injuries are common:

Head, neck and facial injuries

Chest injuries
Intra-abdominal injuries
Lower extremity fractures and dislocations

Cont
Sciatic nerve injuries occur in 10% of hip
dislocations.
*Most commonly, these resolve with
reduction of hip and passage of time.
* Stretching or contusion most common.
*Piercing or transection of nerve by bone
can occur.

Management
History and Evaluation :
Significant trauma, usually RTA.
Awake, alert patients have severe pain in hip
region.
Always follow ATLS guidelinesABCDE

Physical Examination: Classical

Appearance

Posterior Dislocation:

Hip flexed, internally

rotated, adducted.

Physical Examination: Classical

Appearance

Anterior Dislocation:

Extreme external rotation,

less-pronounced abduction
and flexion.

Irregular presentation/appearance if:

femoral head or neck are fractured
femoral shaft fracture
obtunded patient, confused, shocked

Physical Examination
Pain to palpation of hip.
Pain with attempted motion of hip.
Possible neurological impairment:
So,
Thorough exam., is essential pre
reduction!

Radiographs: AP Pelvis X-Ray

In primary survey as per ATLS Protocol.

Should allow diagnosis and show direction of dislocation.
Femoral head not centered in acetabulum (loss of parallelism)
Femoral head appears larger (anterior) or smaller (posterior).
Usually provides enough information to proceed with closed
reduction.

Reasons to Obtain More

X-Rays Before Hip Reduction
View of femoral neck inadequate to rule out
fracture.
Patient requires CT scan of abdomen/pelvis to rule
out associated injuries.

X-rays after Hip Reduction:

AP pelvis, Lateral Hip x-ray.

Judet views of pelvis.
CT scan with 2-3 mm cuts.

CT Scan
Most helpful after hip reduction.
Reveals:
Non-displaced fractures.
Congruity of reduction.
Intra-articular fragments.
Size of bony fragments.

MRI Scan

Will reveal labral tear and soft-tissue anatomy.

Has not been shown to be of benefit in acute
evaluation and treatment of hip dislocations.

Clinical Management:
Emergent Treatment

Dislocated hip is an emergency.

The goal is to reduce risk of AVN and Degenerative
joint disease.

Benefits of early Reduction

Allows restoration of flow through occluded or

compressed vessels.
Literature supports decreased AVN with earlier
reduction.
Requires proper anesthesia.
Requires team (i.e. more than one person).

Patterns Treated Non operatively

No associated fracture and congruent
reduction
Posterior wall fracture that is clinically stable
with congruent reduction
Pipkin type I fracture with congruent
reduction.
Pipkin type II fracture with anatomic
reduction and congruent joint

Anesthesia
General anesthesia with muscle
relaxation facilitates reduction, but is
not necessary, but
Conscious sedation is acceptable.
Attempts at reduction with inadequate analgesia/ sedation
will cause unnecessary pain, muscle spasm and make
subsequent attempts at reduction more difficult.

Reduction Maneuvers
Allis:

Patient supine.
Requires at least two people.

Stimson: Patient prone, hip flexed and

leg off stretcher.
Requires one person.
Impractical in trauma (i.e. most
patients).

Allis Maneuver
Assistant: Stabilizes pelvis
Posterior-directed force on both ASISs

Surgeon: Stands on stretcher

Gently flexes hip to 900
Applies progressively increasing traction to the
extremity
Applies adduction with internal/external rotation
Reduction can often be seen and felt

Reduction of posterior
dislocation
Bigelow maneuver

East Baltimore lift technique

How to know reduced Hip ?

The limb moves more freely
Patient more comfortable
But..
Requires testing of stability
Simply flexing hip to 900 does not
sufficiently test stability

Stability Test
1. Hip flexed to 90o
2. If hip remains stable, apply internal rotation,
adduction and posterior force ??.
3. The amount of flexion, adduction and internal
rotation that is necessary to cause hip dislocation
should be documented.
Caution!: Large posterior wall fractures may make
appreciation of dislocation difficult.

Nonoperative Treatment

If hip stable after reduction, and reduction congruent.

Maintain patient comfort skin traction , analgesia
Avoid Adduction, Internal Rotation.
No flexion > 60o.
Early mobilization usually few days to 2 weeks.
Touch down weight-bearing may be delayed
Repeat x-rays before allowing full weight-bearing.

Irreducible Hip ?
Requires emergent reduction in theatre.
Pre-op CT obtained if it will not cause delay.
One more attempt at closed reduction in O.T. with
anesthesia.
( Repeated efforts not likely to be successful and may
create harm to the neurovascular structures or the
articular cartilage.)
Surgical approach from side of dislocation.

Causes of Irreducible dislocation

Anterior:
Buttonholing through the capsule
Rectus femoris
Capsule
Labrum
Psoas tendon
Posterior:
Piriformis tendon
Gluteus maximus
Capsule, Ligamentum teres
Posterior wall, Bony fragment
Iliofemoral ligament
Labrum

Indications for open Reduction

Irreducible dislocation
Iatrogenic sciatic nerve injury
Incongruent reduction with incarcerated
fragments
Incongruent reduction with soft tissue
interposition
Incongruent reduction with Pipkin type I
femoral head fracture (relative)

Irreducible anterior hip dislocation

Smith-Peterson approach ,Watson-Jones approach,
Extended iliofemoral, ilioinguinal approach.
Allows visualization and retraction of interposed
tissue.
Placement of Schanz pin in intertrochanteric
region of femur will assist in manipulation of the
proximal femur.
Repair capsule, if this can be accomplished
without further dissection.

Irreducible Hip Dislocation: Posterior

Kocher-Langenbeck approach.
Remove interposed tissue, or
release buttonhole.
Repair posterior wall of acetabulum if
fractured and amenable to fixation.

1. Irreducible Posterior Dislocation with Large

Femoral Head Fracture

Fortunately, these are rare.

Difficult to fix femoral head fracture from
posterior approach without transecting
ligamentum teres.

Three Options
1.Detach femoral head from ligamentum teres
repair femoral head fracture with hip dislocated
reduce hip.
2.Close posterior wound, fix femoral head fracture
from anterior approach (either now or later).
3.Ganz trochanteric flip osteotomy.
Best option is not known: Damage to blood supply from
anterior capsulotomy vs. damage to blood supply from
transecting ligamentum teres. Mm

2. Hip Dislocation with Femoral Neck

Fracture
Attempts at closed reduction potentiate chance of
fracture displacement with consequent increased risk of
AVN.
If femoral head is dislocated with neck fracture, then
the ability to reduce the head by closed means is
markedly compromised.
Thus, closed reduction should not be attempted.

Cont..
Usually the dislocation is posterior.
If fracture is non-displaced, stabilize
fracture with parallel lag screws first.
If fracture is displaced, open reduction of
femoral head into acetabulum, reduction of
femoral neck fracture, and stabilization of
femoral neck fracture.

3. Incarcerated
Fragment

Can be detected on x-ray or CT scan.

Surgical removal necessary to prevent abrasive wear of
the articular cartilage.
Posterior approach allows best visualization of
acetabulum (with distraction or intra-op dislocation).
Anterior approach only if:
dislocation was anterior and,
fragment is readily accessible anteriorly.

4. Incongruent Reduction

Acetabulum Fracture (weight-bearing

portion).

Femoral Head Fracture (any portion).

Interposed tissue.
Achieve congruence by removing interposed
tissue and/or reducing and stabilizing fracture.

5. Unstable Hip after Reduction

Due to posterior wall and/or femoral head fracture.
Requires reduction and stabilization fracture.
Labral detachment or tear
Highly uncommon cause of instability.
Its presence in the unstable hip would justify surgical repair.
MRI may be helpful in establishing diagnosis.

Results of Treatment
Pain : normal to severe pain and degeneration.
In general, dislocations with associated femoral head or
acetabulum fractures fare worse.
Dislocations with fractures of both the femoral head and the
acetabulum have a strong association with poor results.
Irreducible hip dislocations have a strong association with poor
results.
13/23 (61%) poor and 3/23 (13%) fair results.
McKee, Garay, Schemitsch, Kreder, Stephen. Irreducible fracture-dislocation of
the hip: a severe injury with a poor prognosis. J Orthop Trauma. 1998.

Complications of Hip Dislocation

1- Avascular Necrosis (AVN): 1-40%
Several authors have shown a positive
correlation between duration of dislocation and
rate of AVN.
Results are best if hip reduced within six hours.

2- Post-traumatic Osteoarthritis
Can occur with or without AVN.
May be unavoidable in cases with severe
cartilaginous injury.
Incidence increases with associated femoral head or
acetabulum fractures.
Efforts to minimize osteoarthritis are best directed at
achieving anatomic reduction of injury and
preventing abrasive wear between articular carrtilage
and sharp bone edges.

3- Recurrent Dislocation
Rare, unless an underlying bony instability has not
been surgically corrected (e.g. excision of large
posterior wall fragment instead of ORIF).
Some cases involve pure dislocation with
inadequate soft-tissue healing may benefit from
surgical imbrication .
Can occur from detached labrum, which would
benefit from repair (rare).

Recurrent Dislocation
Caused by Defect in
Posterior Wall and/or
Femoral Head

Can occur after excision of fractured fragment.

Pelvic or intertrochanteric osteotomy could alter the
alignment of the hip to improve stability.
Bony block could also provide stability.

4- Delayed Diagnosis of Hip Dislocation

Increased incidence in multiple trauma patients.

Higher if patient has altered sensorium.
Results in more difficult closed reduction, higher
incidence of AVN.
In NO Case should a hip dislocation be treated
without reduction.

5- Sciatic Nerve Injury

Occurs in up to 20% of patients with hip
dislocation.
Nerve stretched, compressed or transected.
With reduction:

40% complete resolution

25-35% partial resolution

Sciatic Nerve Palsy:

If No Improvement after 34 Weeks
EMG and Nerve Conduction Studies for
baseline information and for prognosis.
Allows localization of injury in the event that
surgery is required.

6- Foot Drop

Splinting (i.e. ankle-foot-orthosis):

Improves gait
Prevents contracture

7- Infection

Incidence 1-5%
Lowest with prophylactic antibiotics and
limited surgical approaches

8- Iatrogenic Sciatic Nerve Injury

Most common with posterior approach to hip.

Results from prolonged retraction on nerve.

Iatrogenic Sciatic Nerve Injury

Prevention:
Maintain hip in full extension
Maintain knee in flexion
Avoid retractors in greater sciatic notch
? Intra-operative nerve monitoring (SSEP, motor
monitoring)

10- Thromboembolism
Hip dislocation = high risk patient.
Prophylactic treatment with:
low molecular weight heparin
Early postoperative mobilization.
Discontinue prophylaxis after 2-6 weeks (if
patient mobile).

11. Heterotrophic ossification

Higher incidence after open reduction with internal fixation

via an anterior approach than a posterior approach

The use of indomethacin may diminish the rate of clinically

significant heterotrophic ossification.
The other choice is to use radiation therapy, usually 700 Gy
in one dose. This method is very effective in decreasing the
rate of heterotopic ossification, but is not favored in young
patients

Conclusion
It is highly stable joint that needs high
energy trauma to dislocate,(so, don't miss
associated injuries)
Early reduction of the dislocated hip (within
6 hrs) can improve blood flow to femoral
head.
Up to 5 views of xrays/C-T may be needed
for proper evaluation( pre and post
reduction)

Cont..
Minimize closed trials to avoid the risk of
vascular damage and AVN
Surgical approaches according to the
direction of dislocation
Surgeon experience is highly considered for
treatment (as revision surgeies caries a high
risk of complications)

Thank you